Care Plan/Nursing Dx assistance please!!

squishy11 · Oct 28, 2009

I thank you again for your insight into the nursing process. I didn't mean to sound insensitive to my patient. I am veyr sorry to leave, because I almost feel as if I could really do a lot for her. More than she is getting in the LTC.(Of course, when I was there she was my only patient) I think what is making it difficult, is becuase she has had MS for over 20 years, and it seems to me that along with the nursing diagnoisis that could fit with MS, it seems as though she is ready for some wellness dx's and I don't think we are able to use those yet, and am not sure how I would go about measuring a goal for those. I guess what my problem is, is that to say she has a self care deficit with eating, seems like it is a dx that would be ok for someone who has just become diagnosed, or even a self image or depression type of dx. She has expressed that she knows she is not going to get better, and that she is having a hard time being in the LTC (she was just admitted becuase her parents could no longer care for her) because of the age differences as well as the other patients having dementia or the like. But, I also suppose that in a fundamentals course, we are trying to get the gist of writing the plans, so using very simple dx's are what I should make my goal in order to get through the care plan. My pt only has use of her left hand and head, so an immobility diganosis just seems like a given I guess is what I am trying to say.

Again, since this is fundamentals, I suppose that is how I should be looking at this.. (That's what I figuered out last night and actually was able to write a list and prioritze it...)

Thanx again! Every word you write enlightens me :)

Daytonite, BSN, RN · Oct 29, 2009

i thank you again for your insight into the nursing process. i didn't mean to sound insensitive to my patient. i am veyr sorry to leave, because i almost feel as if i could really do a lot for her. more than she is getting in the ltc.(of course, when i was there she was my only patient) i think what is making it difficult, is becuase she has had ms for over 20 years, and it seems to me that along with the nursing diagnoisis that could fit with ms, it seems as though she is ready for some wellness dx's and i don't think we are able to use those yet, and am not sure how i would go about measuring a goal for those. i guess what my problem is, is that to say she has a self care deficit with eating, seems like it is a dx that would be ok for someone who has just become diagnosed, or even a self image or depression type of dx. she has expressed that she knows she is not going to get better, and that she is having a hard time being in the ltc (she was just admitted becuase her parents could no longer care for her) because of the age differences as well as the other patients having dementia or the like. but, i also suppose that in a fundamentals course, we are trying to get the gist of writing the plans, so using very simple dx's are what i should make my goal in order to get through the care plan. my pt only has use of her left hand and head, so an immobility diganosis just seems like a given i guess is what i am trying to say.
again, since this is fundamentals, i suppose that is how i should be looking at this.. (that's what i figuered out last night and actually was able to write a list and prioritze it...)
thanx again! every word you write enlightens me :)

i have to compliment you on your intuition into this patient's nursing problems. let me tell you, however, that a nursing diagnosis is merely a label, an official name, for the nursing problem. don't get too hung up on the name. what is important is the definition of these diagnoses and their symptoms. unlike medical diagnoses which have very precise and defined symptoms, many nursing diagnoses have some broad boundaries that can include a lot of different and varied abnormal assessment findings that can fit with the definition of the problem. that is why our diagnostic "symptoms" are more correctly called defining characteristics. before nursing diagnoses we used to just write "unable to use right hand" on our care plan for the problem (as you can see, scholars figured out that what we were doing was writing symptom (or defining characteristic) after symptom and some of them could be grouped together so our care plans wouldn't be so long because they addressed each symptom); today we write impaired physical mobility.

our interventions and goals would be the same. problems can be new, ongoing and old--acute or chronic--makes no difference. now, your instructors may put limits on what diagnoses you are allowed to use on the paperwork you turn in to them, but that doesn't mean that the patient's problems still don't exist. are you allowed to demonstrate some initiative as a student and use a nursing diagnosis that the instructors haven't gone over with you yet? ask them. what would stop you from, on your own, looking up information about a wellness or self-care diagnosis that you feel would be appropriate for this patient just to satisfy your own curiosity? you are correct and going in the direction that would be most helpful for her. discuss this with your instructor. tell them what diagnoses you feel would be appropriate and see what they have to say. ms is a chronic disease. the best hope is that it would stabilize, but the reality is that it will probably worsen. goalwise, we can help stabilize the function she has left and support any deterioration that does occur. we would all love to have patients that get better and go home, but the reality is that illness and death is a part of the cycle of life and when it comes to supporting the deterioration of life that's a little tougher to put together on a care plan. it also forces us to think about our own frailties and mortality, something that most have either never contemplated before or avoided. it is not the most pleasant of topics.

it is the process of diagnosing that you are being expected to learn. diagnosing is done by many professions and the process is the same: (1) investigate first (2) then draw a conclusion based on what the investigation revealed. one profession that does it backwards that we all know so very well is police work. they start with a crime that was committed (the diagnosis) and then do an investigation to collect the facts (assessment) and find the person (patient) that did it. that won't work for medicine or nursing when you are first exposed to and learning about these diagnoses. for now, as a student, following the nursing process step by step will help you learn to think critically and rationally and become a problem solver which, ultimately, is what a licensed nurse is hired and paid to do. [they didn't tell you that when you signed up for the profession, did they?] this nursing process doesn't just work for care planning. it can be applied to all kinds of problems to help us in coming to a decision. and believe me, as a licensed nurse, that is what you will be doing all day at your job--making decisions about patient care and management.

a good book for learning about care plan construction utilizing the nursing process is nursing care planning made incredibly easy. it comes with a cd that has sample care plans for med/surg, peds, ob and psych conditions that include the abnormal assessment data you would be looking for in those conditions.